BIOETYKA / WPROWADZENIE

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Private Health Insurance: implications for developing countries – WHO 2004

Background and Context s. 6-9

Is there a Role for Private Health Insurance in the Health Policy of Developing Countries?

Unlike taxation and social security, which are commonly viewed as promoting equity, private insurance often conjures up visions of unequal access, large numbers of uninsured people, and elitist health care for the rich. Experience indicates that unregulated or poorly designed private health insurance systems can indeed exacerbate inequalities, provide coverage only for the young and healthy, and lead to cost escalation.

However, when appropriately managed, private health insurance can play a positive role in improving access and equity in developing countries for several reasons.

1. First, out-of-pocket spending on health services is the most common form of health financing in developing countries and represents a significant financial burden for households. To the extent that private insurance gives households an opportunity to avoid large out-of-pocket expenditures, it can provide access to financial protection that is otherwise lacking.

2. Secondly, many developing countries have public expenditures for health of less than $10 per capita per year, with large informal sectors. Their ability to generate tax revenues or fund social insurance systems to provide broad financial protection for health care is limited. Private coverage, when appropriately regulated, may be one way to move towards prepayment and risk pooling until publicly funded coverage can expand sufficiently. It also allows policy makers to target limited public resources towards the most vulnerable groups, while those who can afford it, can contribute to their medical costs.

3. Thirdly, history shows that the social insurance systems of several OECD countries evolved from voluntary private health insurance schemes based on professional guilds or communities. These historical lessons in building institutional capacity and the changing role of private coverage as public financing is strengthened, may be useful in informing policy debates in developing countries as they consider moving towards public insurance systems.

4. Finally, private health insurance continues to be important even in countries where universal coverage has been achieved. Policy makers who plan ahead for this supplementary role will be better prepared to ensure that private coverage will complement public systems as they develop.

The OECD Adhoc Group on Private Insurance uses the difference in how insurance is funded as the key criterion to distinguish between private and public insurance.

• Whether insurance is mandatory or voluntary.

• Whether contributions are risk rated (minimal risk transfer), community rated (transfer of risk between healthy and sick) or income based (transfer of risk between healthy and sick; and higher income and lower income).

• Whether management of the scheme is commercial for-profit, private non-profit, or public/quasi-public.

Countries with the Highest Private Insurance Expenditures s.11-12

Three of these are adjoining countries in Sub-Saharan Africa: Namibia, South Africa and Zimbabwe, while three are in South America: Uruguay, Chile, Brazil. while three are in South America: Uruguay, Chile, and Brazil.

The United States is the only rich country to rely on voluntary private insurance to provide coverage to most of its people

These seven countries differ significantly in their income levels, the percentage of people covered through private insurance and the extent of effective regulation of the private market. However, they have several similarities worth noting: in each country private insurance provides principal coverage targeted largely at the formal, employed workforce and their families. And in each country, vulnerable populations are covered through publicly funded programs.

Implications for Policy Makers in Developing Countries s. 12-13

As developing country policy makers consider whether they will allow private insurance to emerge or, if it already exists, how they can better manage the market, a few lessons are important from the experiences of developed countries.

First, no high-income country uses private coverage as the primary method for insuring poor or high-risk populations.

Second, government stewardship of health insurance markets is critical to their effective functioning.

Finally, as the experiences of Germany, the Netherlands and Sweden show, as countries move towards universal coverage, the role of private health insurance can change.